


No Win Scenarios

by jinajema



Category: Star Trek: Alternate Original Series (Movies)
Genre: Academy Era, Emotional Hurt/Comfort, Gen, Medical Jargon, basically a bones monologue, graphic description of medical procedures, it's weird calling bones "leonard", jargon explained/expanded on in notes
Language: English
Status: Completed
Published: 2020-06-09
Updated: 2020-06-09
Packaged: 2021-03-04 03:15:40
Rating: Teen And Up Audiences
Warnings: Creator Chose Not To Use Archive Warnings
Chapters: 1
Words: 1,861
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/24626878
Author URL: https://archiveofourown.org/users/jinajema/pseuds/jinajema
Summary: Bones accidentally wakes Jim up at night after a bad day on the wards at the Academy hospital. Jim listens.
Relationships: James T. Kirk & Leonard "Bones" McCoy
Comments: 3
Kudos: 26





	No Win Scenarios

Leonard rummages around in the cabinet, pulling out bottles and setting them on the counter until he at last procures the Tennessee whiskey he saves for special occasions - good and bad. With a sigh, he extracts the bottle and it thunks on the counter, harder than he intended it to.

“Wha’s goin’ on, Bones?” Jim’s sleepy voice grows louder as he shuffles into the kitchen of Leonard’s apartment.

“Dammit”, Leonard swears, “Sorry kid. Didn’t mean to wake ya. Go on, go back to sleep.” He turns away from Jim, hiding his face toward the cabinets as he procures a glass. Times like these he wished Jim would just stay in his own dorm at the Academy, but more often then not Leonard was grateful for his defacto roommate, if not for the companionship in his more spacious officer’s apartment, but also for the accessibility whenever Jim did anything stupid and needed patching up. Amber liquid trickled into the glass, carving tiny rivers into the sphere of ice. He turns and swears again, Jim’s bright blue eyes clouded with sleep and concern much closer than he had anticipated. 

“You wanna talk about it?” Jim asks, not giving Leonard the time to answer as he prods the replicator until it produces two steaming mugs of camomile tea. He grabs the mugs and sits down at the kitchen table, setting one in front of himself and the other in front of the empty chair that he kicks away from the table as he sprawls backward, rubbing his eyes. Leonard sinks into the chair, his eyes glued to the whiskey until he drains his glass. He moves to refill it and startles as Jim’s hand gently removes the glass, replacing it with the mug of steaming tea.

“C’mon Bones,” Jim says softly. “It’s four in the morning. You can talk to me.”

Leonard inhales a shaky breath, acutely aware that their normal roles were reversed in this situation. 

“You don’t believe in no win scenarios,” Leonard says roughly. Brown eyes lift to bright blue, and harden. “But I do. They’re real, I’ve seen ‘em, and I just -” He sighs. “I can’t get ‘em out of my head, kid. The Academy’s got me on the gomer service. I know we’re not s’posed to use that word anymore - it’s not appropriate, it’s not right and all that. But it’s recognizin’ defeat as soon as the patient rolls in the door, knowin’ there’s nothin' you can do to stop their inevitable decline and death.”

Jim nods, uncharacteristically lost for words. To him, Bones was invincible. Unflappable. Sure, he swore and blustered and hovered like a mother hen sometimes, but he was damn good at his job. In the short training missions he’d been sent on as part of his Academy coursework, he’d seen Bones bring humanoids of all species back from the brink of death, not even pausing to marvel in it before moving on to the next in need. He wills himself to stay silent, waiting for his friend to continue.

“They’ve got me on medicine right now, obviously,” Leonard continues, as if that were actually obvious. “And it’s just - in all the advances we’ve made, in the goddamn 23rd century, there are still patients where there’s just nothin' we can do. We can’t beat physiology. Not when it’s gone on so far.

“I had a patient today, older man, maybe 60s, 70s. Drinker,” he nods apologetically, knowing Jim’s mind would flash back to Frank. “He’d cut out drinkin', kicked the habit, moved on. But the damage was done, from the alcohol and never going to a damn doctor in the last 20 years of his life.

“Cirrhosis is a special type of pathophysiological hell. The liver turns hard, and blood can’t flow through it so good anymore.” Leonard’s drawl exaggerates, and Jim wonders whether the whiskey was his first drink of the night. “But the body’s resilient. The blood vessels dilate, lettin' the tissue get oxygen and nutrients, and it seems like it’s going to be okay. But no, the more blood that goes to the liver draws blood away from the rest of the body. The kidneys’ system goes haywire, and in the attempt to fix itself the problem only gets worse.

“This patient, the lucky bastard, his damn pancreas had to join in on the fun. I’d guess he had pancreatitis eight, ten, twelve times, because when we got into the abdomen to fix his bowel obstruction there was nothin'. Every tissue, fused together. No way to tell scar from bowel from blood vessel. No way to separate it, not even with the Fleet’s newest laser scalpels. No definitive end or beginnin', just a mass of tissue, congealed together. 

“So we closed him up. His bowel’s obstructed, and tonight he’s gonna perforate, and then he’s gonna die. A few days of sepsis, delirium, until eventual death, and there’s nothin' we can do, even in the goddamn 23rd century.”

Leonard’s knuckles are white, his fingers wrapped tightly around the mug, eyes staring blankly at the table.

“I’m sorry,” Jim says softly, reaching out a hand to set on his friend’s arm before deciding better of it, letting his fingers fall to rest palm up on the table. 

“And that’s not even the half of it,” Leonard says bitterly. Jim flinches as Leonard’s chair flies backward, nearly toppling over as the older man begins to pace. 

“Sometimes it’s not even what we can do, it’s what we do do. Back in medical school in Georgia, there was one patient. An old lady, like a really old one, in her 110s. All the 23rd century medicine in the world was keepin’ her alive, but couldn’t stop her dementia. She’d been livin’ at home, with family, when she wandered durin' the night, like those patients always do.” 

Leonard continues to wear a path in the grey carpet as the words tumble out.

“She tripped and fell. Came into the hospital durin’ chaos. Some engineerin’ lab and been working on a new core stabilizer in the Atlanta shipyard, and instead of stabilizin’ it let out some sort of electromagnetic blast. It knocked everythin’ out. PADDs, trichorders, ventilators, anything that was runnin’ or on standby. We were flyin’ blind.

“Anyway, this lady comes in and I can tell she’s a goner. The first responders had her nose packed with gauze, and there was still a river of red runnin' out so fast she was chokin’ and gaggin’ on it. The family was there too, yellin’ at us to do everythin’ we could. I guess they felt bad, not keepin’ a closer eye on her, but it ain’t their fault. I know how hard it is to take care of someone with dementia. I watched my own grandpa forget who I was, then forget who he was until he just sat there, bitter and frightened in a world he couldn't recognize until the day he died.

“The family wanted us to do everythin', so we did. We hooked up suction and pulled a near liter of blood out of her throat so that we could intubate. The suction pulled two more liters from her nose. Her face was swellin’ up, eyelids purple and huge. Her ribs were broken - didn’t need a tricorder to feel that one, so we threw chest tubes and pulled liters of blood out of her pleural cavity too. We had her on MTP, but the blood was pourin’ out of her faster than we could get it in.

“She crashed and we started CPR. No one does CPR anymore ‘cause it’s gruesome and doesn’t work. Even back in the day, only 11% of patients who got CPR ever ended up leavin' the hospital, or somethin' like that. Some woke back up, sure, but if you’re in that state there’s not much that can be done. 

“So I stood on the stool, my gloved hands over her bare chest, sweat drippin’ into my eyes and off my chin as her ribs cracked beneath me. We did round after round after round of CPR and cordrazine, CPR and cordrazine, prayin’ for a shockable rhythm.

“But she came back, without the shock, and for a moment everythin' seemed like it would be fine. At this point it’d been about an hour, and the trichorders were finally back on. We were runnin’ the angiography setting - takes a little longer than what we use out in the field with the fleet - and in those minutes, everythin’ began leakin’.

“Her IVs, her chest tubes, her nose. Everywhere. DIC. The body gone so haywire that it clots where it shouldn’t and bleeds where the clots should’ve been. By the time the scan finished she was lyin’ in a pool of her own blood.

“There was nothin’ we could do. Sheared her goddamn carotid in the deepest, hardest to access part of her brain. So after all that we stepped back to let nature take her course. There were tubes stickin’ out everywhere - her mouth, her nose, both arms, both sides of the chest. Hell we even had IO access going too. Her face was purple and swollen from the trauma and the CPR and the 20 units of blood and platelets and saline we’d shoved in that were poolin’ around her. 

“We covered her as best we could with the sheets - the family didn’t need to see all those lines and tubes. I was wipin’ the blood off her face, the only part of her we’d left visible, when the whole family came in. There were kids just 16 or 17, great-grandkids I suppose, and I was covered in their grandma’s blood, wipin’ a face now unrecognizable.

“What good did we do?” Leonard flops back in the chair, taking a large gulp of the tea that had cooled as he’d paced. 

“We couldn’t save her. And instead of lettin’ her family hold her hand, be there supportin’ her, we played every card in the deck knowin’ it wouldn’t do a damn thing to change the fact that she was gonna die.

“Don’t let 'em do that to me, Jim Kirk,” Leonard says suddenly, his hand wrapping around Jim’s wrist, brown eyes shrouded by a ring of desperation Jim had never seen before. Jim moved to open his mouth in protest.

“I’m serious. Save me if I’m savable. But don’t you dare let ‘em go after me with everythin’ and the kitchen sink when it’s not gonna do anythin’ at all. I’d rather have my last moments filled with a little peace. I’d rather die with friends than in the operatin’ room of a damn starship tryin’ to replicate a new heart that got blown straight outta my chest.”

Jim winces at the image, and lets his other hand rest on top of his friend’s.

“You got it, Bones.” His voice comes out as barely a whisper.

The men stand, and Jim pulls Leonard into the tightest hug he can muster. He doesn’t say anything when Leonard begins to shudder, or when tears begin to dampen his shirt over his right shoulder. They simply stand. 

Maybe this once, Jim Kirk believes in no win scenarios.

**Author's Note:**

> Gomer: "get out of my emergency room," characterizes difficult and persistent patients who continuously return with unresolved, chronic conditions.
> 
> Cirrhosis: condition in which liver does not function due to damage, due to viral hepatitis, alcoholic hepatitis, non-alcoholic steatohepatitis, drug induced liver injury, etc. Leads to fibrosis, necrosis, and regenerative nodules within the liver parenchyma, as well as decline of productive, secretory, and detoxification functions.
> 
> Ascites: abnormal build up of fluid within the peritoneal cavity of the abdomen resulting from extravascular fluid leakage due to hypoalbuminemia and portal hypertension, defined as elevation of hepatic venous pressure, caused by increased intrahepatic resistance to blood flow in the setting of cirrhosis. Endotoxins released from cirrhotic liver stimulate the production of inflammatory cytokines, which stimulate the release of nitric oxide. Nitric oxide causes splanchnic vasodilation, which improves blood flow in the portal venous system of the liver, but decreases systemic vascular resistance and decreases extracellular circulating volume, which leads to the activation of the renin-angiotensin-aldosterone system and non-osmotic release of antidiuretic hormone. Combined, these changes lead to sodium and water retention, leading to peripheral edema and worsening of ascites. Worsening ascites obstructs venous return to the heart at the level of the inferior vena cava, which further contributes to lower extremity edema. 
> 
> Bowel obstruction: most often due to hernia or adhesion from prior surgery, causes blockage of stool passage. Without treatment causes bowel rupture and leakage of stool in the abdominal cavity, causing peritonitis, infection, and death without treatment.
> 
> Pancreatitis: inflammation of the pancreas. Acutely, is idiopathic or secondary to gallstones, alcohol, trauma, posterior duodenal ulcer rupture, scorpion stings, mumps, autoimmune, steroids, or medications. Chronically, most often secondary to recurrent acute pancreatitis secondary to alcohol use. 
> 
> Frozen abdomen: complication of recurrent abdominal surgery or necrotizing pancreatitis, in which intraabdominal adhesions form between the anterior abdominal wall and abdominal viscera.
> 
> MTP: massive transfusion protocol, provides rapid blood replacement in the setting of severe hemorrhage.
> 
> Angiography: the use of intravenous contrast to visualize blood vessels.
> 
> DIC: disseminated intravascular coagulation; systemic activation of blood coagulation results in generation and deposition of fibrin, leading to microvascular thrombi in various organs. Can result in life-threatening hemorrhage.
> 
> IO access: intraosseous access; in which fluids are transfused directly into bone in the setting of difficult vascular access, such as hemorrhagic shock.
> 
> Advanced directive: legal document outlining the medical interventions desired by an individual in given circumstances when that individual is incapacitated. Highly encouraged that all readers of all ages create their own, and encourage family members to do so as well.


End file.
